the fIrst ever Global survey on avaIlabIlIty and barrIers to access of opIoId analGesIcs for patIents In paIn

Global access to paIn relIef: evIdence for actIon

Conducted in 81 countries and 25 Indian

states, representing 87% of the global

population, this survey provides a

comprehensive view of access to pain relief

for cancer patients in need. The survey

reveals multiple barriers to routine use of

low cost, efficacious pain management in

the form of morphine and other opioid

analgesics in most countries worldwide.

Global dIsparItIes In access to paIn relIef Vast and unacceptable disparities in access to pain relief exist between developed and developing countries. Across the developing world, internationally recommended medicines, indispensible to treat moderate to severe pain, are scarce and unnecessarily difficult for patients to access. The World Health Organization (WHO) estimates there are 5 billion people living in countries with little or no access to pain medicines, including 5.5 million terminal cancer patients and millions of others suffering from acute illness and end-of-life suffering. Among patients with terminal cancer, 80% are estimated to experience moderate to severe pain due to inequitable access to medicine.ii

pallIatIve care aims to improve the quality of life of patients suffering life-threatening illness, and their families through the prevention and relief of suffering through the treatment of pain and other problems, physical, psychosocial and spiritual.

untreated deaths In paIn In 2010. Source: www.GAPRI.org

The 2012 international survey on the availability and accessibility of opioids for cancer pain management was coordinated by the European Society for Medical Oncology (ESMO), the European Association Palliative Care (EAPC), the International Program at the Pain and Policy Studies Group, University of Wisconsin Carbone Cancer Center (PPSG), the Union for International Cancer Control (UICC), and the World Health Organization (WHO), in collaboration with 17 leading cancer and palliative care organizations worldwide: http://www.esmo.org/content/download/8637/175558/file/ESMO-Opioid-Survey-Data-International-Collaborative-Partnership-List.pdf

The 2012 survey, is a global expansion of the ESMO-EAPC survey of European countries in 2010. Led by ESMO’s Palliative Care Working Group and Developing Countries Task Force, the survey gathered data on the legal, regulatory and social barriers determining the availability and access to seven essential opioids for cancer pain management in Africa, Asia, Latin America & the Caribbean, and the Middle East. The opioids included in the survey were selected based on the WHO Model Essential Medicines List and the International Association for Hospice and Palliative Care list of essential medicines for palliative care. Between December 2010 and July 2012, researchers had clinicians in 81 countries and 25 Indian states complete in-depth questionnaires on formulary availability, cost and barriers to accessing essential opioids, to measure current national standards against the international standards established by the INCB and the WHO. Final data will be officially published in 2013 as a Supplement of Annals of Oncology and supported by an international advocacy campaign to promote the implementation of the changes recommended in the peer-reviewed publication.

In developed countries, a growing commitment to palliative care and recognition of the vital role of legitimate medical use of opioid-based analgesics for moderate to severe pain relief has created a rise in opioid consumption over the past several decades.iii

The disparities in worldwide use are shocking, with just four countries—United States, Canada, United Kingdom and Australia—using 68% of opioids, while low and middle-income countries together only account for 7% of global use.iv

Global medIcal opIod consumptIon

neW data: the esmo-led InternatIonal collaboratIve surveyThis landmark survey provides the most comprehensive overview of the availability of seven medical opioids, and policy obstacles to their use, throughout the developing world. These important findings can help policy makers, clinicians and advocates effectively reform policies and practices in their countries to align with international standards and make pain relief available to those in need.

The survey revealed that with few notable exceptions, most governments in Africa, Asia, Latin America & the Caribbean, and the Middle East are failing to consistently or adequately alleviate the pain and suffering of cancer patients in their countries. Even where the opioids are available, cost to the patient and pervasive overregulation make them virtually inaccessible to millions in need.

Source: www.GAPRI.org

the Good neWsThe good news is that opioids are not expensive, in short supply or difficult or dangerous to administer when used correctly. Unlike other medicines, opioid analgesics used to treat moderate to severe pain—such as morphine—are largely not under patent protection and can be produced inexpensively at sufficient quantities to meet global need.

A clear understanding of the barriers restricting availability and access is critical for pain relief advocates and their partners in national governments, civil society and the private sector to work together for national change. A 2012 survey led by the European Society for Medical Oncology (ESMO) provides this vital information.

Sources: N.I Cherny, J. Baselga, F. de Conno and L. Radbruch, “Formulary availability and regulatory barriers to accessibility of opioids for cancer pain in Europe: a report from the ESMO/EAPC Opioid Policy Initiative. N.I. Cherny, The international collaborative project to evaluate the availability and accessibility of opioids for the management of cancer pain in Africa, Asia, Latin America & the Caribbean, and the Middle East. ESMO Palliative Care Working Group. Available at: http://www.esmo.org/Policy/International-Access-to-Opioids-Survey

the barrIers to avaIlabIlIty and access to paIn relIef

i. essential opioids not available

essential opioids were included on national essential medicines lists in all regions of the world, but were not consistently available anywhere.

In all regions, many of the 7 essential opioids were on national essential medicines lists (EML). With few exceptions, codeine and at least one, often more, morphine formulations were on national lists. Oxycodone, Methadone and Fentanyl were less consistently included on formularies, but also common. Yet, data revealed that in many of the countries and all of the Indian states surveyed, fewer than 3 of the 7 medicines were routinely available in hospital dispensaries and pharmacies.v

In the Indian states, despite codeine, three morphine formulations and fentanyl commonly being on state-level essential medicine lists, only codeine is always or usually available. The 6 other medicines considered essential for pain management are either occasionally or never available.

All regions of the world show similar inconsistencies between adherence to global standards at the national policy level and the actual range and availability of essential opioids to patients.

ii. outdated policies discourage access

the survey found with few exceptions, outdated and unnecessarily stringent legal and regulatory restrictions impede clinicians’ ability to prescribe and dispense pain medicines.

Nearly all of the 81 countries surveyed have a range of strict policies and regulations, which prevent pain relief from being integrated into patient care and create roadblocks to access. The research showed that 84% of countries had four or more policy-related barriers that severely limited patient access to pain relief. Across all regions, limitations were found on the types of hospitals or wards where opioids can be administered, the dose and length of time allowed by a single prescription and which clinician can prescribe opioids. These restrictions disincentivize clinicians from prescribing and create insurmountable barriers for pharmacists and families seeking access to pain medicines.

Survey SPurS reform in indiaBased on the results of the ESMO survey, the Indian Association of Palliative Care (IAPC) mounted a successful advocacy campaign in the national media. As a result, the Supreme Court of India issued directives to all Indian States to ensure availability and ease of access to morphine to treat pain in terminally ill cancer patients. It is anticipated that a new bill amending the existing complex rules will be sent to Parliament for approval shortly.

opIoId access for hospIce patIents

Source: N.I. Cherny, The international collaborative project to evaluate the availability and accessibility of opioids for the management of cancer pain in Africa, Asia, Latin America & the Caribbean, and the Middle East. ESMO Palliative Care Working Group. Available at: http://www.esmo.org/Policy/International-Access-to-Opioids-Survey

Sources: N.I Cherny, J. Baselga, F. de Conno and L. Radbruch, “Formulary availability and regulatory barriers to accessibility of opioids for cancer pain in Europe: a report from the ESMO/EAPC Opioid Policy Initiative. N.I. Cherny, The international collaborative project to evaluate the availability and accessibility of opioids for the management of cancer pain in Africa, Asia, Latin America & Caribbean and the Middle East. ESMO Palliative Care Working Group. Available at: http://www.esmo.org/Policy/International-Access-to-Opioids-Survey

iii. limited awareness and unnecessary administrative obstacles

patient demand and access to pain medicines is severely limited by unnecessary administrative obstacles and costs.

Public misconceptions about safety, such as concerns about addiction to opioids, and lack of awareness about their effectiveness for pain relief, has resulted in little demand for these medicines from patients and their families. For those who are aware of the value and do seek access, the survey documented significant barriers limiting patient access. Complicated prescription forms, little government subsidization, inflated costs for medicines at the point of sale, and strict limits on the dosage of medicine provided—regardless of patient pain levels—are among the many discouraging challenges faced by millions seeking adequate access to affordable pain relief for themselves or their loved ones.

iv. Inadequate clinician education and empowerment

Inadequate clinician education and recurring misconceptions are persistent barriers to increased opioid use throughout the developing world.

Clinicians must be educated, informed and legally empowered to prescribe as they see fit based on individual patients needs. Although not a focus of the ESMO survey, there is broad consensus among the international community that inadequate education of health care providers is one of the most pervasive and urgent obstacles to address. A recent Human Rights Watch survey on palliative care barriers in 40 countries found that most countries had inadequate medical education in palliative care and pain management and four of the countries surveyed had no relevant curriculum in these areas at all.vi

Government subsIdIes to reduce patIent cost

need for freQuent refIlls

Global momentum for chanGetoday, pain relief is widely understood as a patient right and a human right. the Who and International narcotics control board (Incb) are increasing their efforts to encourage national governments to align their policies with international standards.

Although important precautions must be taken to prevent misuse of opioids, well-established global standards call for all countries to have balanced policies that ensure opioid analgesics are both available (i.e. present in hospital dispensaries and pharmacies) and accessible (i.e. affordable for patients with a prescription for the length of time and in the quantity required) to those in need. For more than 50 years, the international community has strongly backed the rational and responsible use of opioids to treat pain. Since the signing of the Single Convention on Narcotic Drugs (1961), narcotics control and international public health agencies, led by the INCB, Commission on Narcotic Drugs and UN Office on Drugs and Crime and the WHO, have established policies and programmes to encourage the responsible use of these medicines.

Challenged to develop reasonable systems to regulate these medicines, many developing country governments have limited the availability or supply of these medicines in-country and put strict policies in place that govern their prescription, dispensation and consumption. These policies have essentially cut off access to the majority of people in need, patients in pain. In order to better align drug management policies and systems with global need, vital work is underway within the drug control and public health communities to help partner countries implement new and responsible approaches to control that allow for greater access to those in need. The INCB and WHO have expanded their engagement with developing country governments and re-articulated their calls for countries to better balance efforts to ensure access with regulatory and legal frameworks that prevent misuse.

The global public health community is further expanding these calls for national policy reform. Increasingly, emerging chronic disease management strategies, plans and policies all call for the integration of palliative care and pain relief as a patient right and human right. This consensus is particularly evident in the new WHO Global Monitoring Framework for the Prevention and Control of Non-communicable Diseases (NCDs) adopted in November 2012, and the draft WHO Global Action Plan for NCDs 2013-2020. These documents call for greater government commitment to pain relief and call for pain relief and palliative care to be integrated within the continuum of care for prevention, detection, treatment and care of cancer and other chronic diseases. These are among the many indications of strong global consensus and an urgent call for greater leadership and policy change at the national level.vii

“medical use of narcotic drugs continues to be indispensable for the relief of pain and suffering and adequate provision must be made to ensure the availability of narcotic drugs for such purposes.”

The United Nations Single Convention on Narcotic Drugs,

signed in 1961.

TreaT The Pain is a programme of the American Cancer Society to make effective pain medicines universally available by 2020. Treat the Pain works with governments and partners in low and middle-income countries to promote sustainable improvements in public sector medicine availability, reduce the cost and improve the availability of medicines, and improve the skills and motivation of individual clinicians. For more information about Treat the Pain and access to pain relief, please visit www.TreatThePain.org or www.facebook.com/TreatThePain

next steps Backed by the call for the integration of palliative care and pain relief within the draft WHO Global Action Plan for NCDs 2013-2020, the time has come for governments, civil society and international agencies to come together to put new models, policies and approaches for pain relief into place.

No single approach will work across regions—as the historical, legal and social influences that shape the use of these medications are country specific. However, as evidenced in the survey, there are more commonalities than differences in the obstacles and misinformation that is shaping use across regions. Fortunately, there are countries in each region—including Uganda, Vietnam, Nepal, Jamaica—where recent government leadership, civil society engagement and education and mobilization of clinicians have resulted in important and replicable policy change and increased access to pain medications.

In each of these countries, the reform of national drug control and public health policies that impede medical access was an essential early step. Recent international commitments such as the 2011 UN Political Declaration on NCDs can serve as an important rallying call for those countries to take the first step. In a key development, the Executive Board of the WHO and World Health Assembly (WHA) are expected to discuss palliative care needs and barriers in 2014, and propose a palliative care resolution for adoption by governments at the WHA.

referencesi The World Health Organization Briefing Note-February 2009. Access to Controlled Medications Programme: Improving access to medications controlled under international drug conventions. Available from: http://www.who.int/medicines/areas/quality_safety/ACMP_BrNoteGenrl_EN_Feb09.pdf

ii Global Alliance to Pain Relief Initiative (GAPRI). Access to Essential Pain Medicines Brief (2010). Available from: http://www.gapri.org/understand-problem

iii The World Health Organization. Ensuring balance in national policies on controlled substances: Guidance for Availability and Accessibility of Controlled Medicines. Available from: http://apps.who.int/medicinedocs/documents/s18050en/s18050en.pdf

iv Global Alliance to Pain Relief Initiative (GAPRI). Access to Essential Pain Medicines Brief (2010). Available from: http://www.gapri.org/understand-problem

v The First International Survey on Availability of Opioids for Cancer Pain Management: Data Results for Africa, Asia, Latin America & the Caribbean and the Middle East. Data available by region from: http://www.esmo.org/Policy/International-Access-to-Opioids-Survey

vi Human Rights Watch. Global State of Pain Treatment: Access to Palliative Care as a Human Right. May 2011. Available from: http://www.hrw.org/sites/default/files/reports/hhr0511W.pdf

vii The World Health Organization. Report on the Formal meeting of Member States to conclude the work on the comprehensive global monitoring framework, including indicators, and a set of voluntary global targets for the prevention and control of non communicable diseases. November 2012. Available from: http://apps.who.int/gb/ebwha/pdf_files/EB132/B132_6-en.pdf

Call To aCTionThe ESMO-led survey provides clear evidence of the policy barriers that countries should address to align their countries with current global standards of care for cancer, other NCDs and life-threatening and limiting illnesses.

For the 81 countries covered in the survey, advocates and their government partners now have specific and relevant information with which to seek more rational and appropriate policies to improve access to pain medicines.

Once policies are updated, the inclusion of pain relief within a continuum of care strategy for cancer in National Cancer Control Plans and other disease specific and mutisectoral plans will allow new policies to be put into practice at scale. As called for in the WHO Global Monitoring Framework for the Prevention and Control of NCDs, national monitoring and reporting on efforts will be essential to continually improve on our ability to deliver pain relief to those in need.

However, governments cannot do this alone. To take advantage of the current momentum, cancer advocates must work swiftly to mobilize other civil society groups and health advocates, and work together to engage the general public and the media to create change. In this effort, the ESMO-led survey provides essential detail on key advocacy and policy priorities that if addressed could swiftly improve access to pain medicines throughout the world.

this brief was written by sarah Goltz, mph, mIa and aubrey cody, mph of sage Innovation.